Implementation Science (IMPLEMENT SCI )

Publisher: BioMed Central Ltd


Implementation Science is an open access, peer-reviewed online journal that aims to publish research relevant to the scientific study of methods to promote the uptake of research findings into routine healthcare in both clinical and policy contexts. Biomedical research constantly produces new findings - but often these are not routinely translated into health care practice. Implementation research is the scientific study of methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, and hence to improve the quality and effectiveness of health care. It includes the study of influences on healthcare professional and organisational behaviour.

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Publications in this journal

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    ABSTRACT: Background: Identifying, developing, and testing implementation strategies is an important goal of implementation science. However, these efforts have been complicated by the use of inconsistent language and inadequate descriptions of implementation strategies in the literature. The Expert Recommendations for Implementing Change (ERIC) study, aimed to refine a published compilation of implementation strategy terms and definitions by systematically gathering input from a wide range of stakeholders with expertise in implementation science and clinical practice. Methods: Purposive sampling was used to recruit a panel of experts in implementation and clinical practice who engaged in three rounds of a modified Delphi process to generate consensus on implementation strategies and definitions. The first and second rounds involved web-based surveys soliciting comments on implementation strategy terms and definitions. After each round, iterative refinements were made based upon participant feedback. The third round involved a live polling and consensus process via a web-based platform and conference call. Results: Participants identified substantial concerns with 31% of the terms and/or definitions, and suggested five additional strategies. 75% of definitions from the originally published compilation of strategies were retained after voting. Ultimately, the expert panel reached consensus on a final compilation of 73 implementation strategies. Conclusions: This research advances the field by improving the conceptual clarity, relevance, and comprehensiveness of implementation strategies that can be used in isolation or combination in implementation research and practice. Future phases of ERIC will focus on developing conceptually distinct categories of strategies as well as ratings for each strategy’s importance and feasibility. Next, the expert panel will recommend multifaceted strategies for concrete real-world scenarios that differ in terms of the evidence-based programs and practices being implemented and the strength of contextual supports that surround the effort.
    Implementation Science 03/2015;
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    David A Dorr, Kenneth McConnell, Marsha Williams, Kimberley A Gray, Jesse Wagner, Lyle J Fagnan, Elizabeth Malcolm
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    ABSTRACT: Background Health care in the United States is in the midst of a near perfect storm: strong cost pressures, dramatic redesign efforts like patient-centered medical homes and accountable care organizations, and a broad series of payment and eligibility reforms. To date, alternative models of care intended to reduce costs and improve outcomes have shown mixed effects in the U.S., in part due to the difficulty of performing rigorous evaluation studies that control for the broader transformation while avoiding other biases, such as organizational or clinic effect on individual patient outcomes. Our objective is to test whether clinics assigned to achieve high value elements (HVEs) of practice redesign are more likely than controls to achieve improvements in patient health and satisfaction with care and reduction in costs.Methods/DesignTo prepare, we interview stakeholders, align with health reform, and propose a pilot. Participants are primary care clinics engaged in reform. Study protocol requires that both arms receive monthly practice facilitation, IT-based milestone reporting, and small financial incentives based on self-determined quality improvement (QI) goals; intervention receives additional prompting to choose HVEs. Design is a cluster randomized controlled trial over 1 year with pre- and post-washout periods. Outcomes are unplanned utilization and costs, patient experience of care, quality, and team performance. Analysis is a multivariate difference-in-difference with adjustments for patient risk, intraclinic correlation, and other confounders.DiscussionThe TOPMED study is a cluster randomized controlled trial focused on learning how primary care practices can transform within health reform guidelines to achieve outcomes related to the Triple Aim.Trial registration: NCT02106221.
    Implementation Science 01/2015; 10(1):13.
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    ABSTRACT: Background Evidence shows that clinical audit and feedback can significantly improve compliance with desired practice, but it is unclear when and how it is effective. Audit and feedback is likely to be more effective when feedback messages can influence barriers to behavior change, but barriers to change differ across individual health-care providers, stemming from differences in providers¿ individual characteristics.DiscussionThe purpose of this article is to invite debate and direct research attention towards a novel audit and feedback component that could enable interventions to adapt to barriers to behavior change for individual health-care providers: computer-supported tailoring of feedback messages. We argue that, by leveraging available clinical data, theory-informed knowledge about behavior change, and the knowledge of clinical supervisors or peers who deliver feedback messages, a software application that supports feedback message tailoring could improve feedback message relevance for barriers to behavior change, thereby increasing the effectiveness of audit and feedback interventions. We describe a prototype system that supports the provision of tailored feedback messages by generating a menu of graphical and textual messages with associated descriptions of targeted barriers to behavior change. Supervisors could use the menu to select messages based on their awareness of each feedback recipient¿s specific barriers to behavior change. We anticipate that such a system, if designed appropriately, could guide supervisors towards giving more effective feedback for health-care providers.SummaryA foundation of evidence and knowledge in related health research domains supports the development of feedback message tailoring systems for clinical audit and feedback. Creating and evaluating computer-supported feedback tailoring tools is a promising approach to improving the effectiveness of clinical audit and feedback.
    Implementation Science 01/2015; 10(1):12.
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    ABSTRACT: Background Leadership is important in the implementation of innovation in business, health, and allied health care settings. Yet there is a need for empirically validated organizational interventions for coordinated leadership and organizational development strategies to facilitate effective evidence-based practice (EBP) implementation. This paper describes the initial feasibility, acceptability, and perceived utility of the Leadership and Organizational Change for Implementation (LOCI) intervention. A transdisciplinary team of investigators and community stakeholders worked together to develop and test a leadership and organizational strategy to promote effective leadership for implementing EBPs.Methods Participants were 12 mental health service team leaders and their staff (n¿=¿100) from three different agencies that provide mental health services to children and families in California, USA. Supervisors were randomly assigned to the 6-month LOCI intervention or to a two-session leadership webinar control condition provided by a well-known leadership training organization. We utilized mixed methods with quantitative surveys and qualitative data collected via surveys and focus groups with LOCI trainees.ResultsQuantitative and qualitative analyses support the LOCI training and organizational strategy intervention in regard to feasibility, acceptability, and perceived utility, as well as impact on leader and supervisee-rated outcomes.Conclusions The LOCI leadership and organizational change for implementation intervention is a feasible and acceptable strategy that has utility to improve staff-rated leadership for EBP implementation. Further studies are needed to conduct rigorous tests of the proximal and distal impacts of LOCI on leader behaviors, implementation leadership, organizational context, and implementation outcomes. The results of this study suggest that LOCI may be a viable strategy to support organizations in preparing for the implementation and sustainment of EBP.
    Implementation Science 01/2015; 10(1):11.
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    ABSTRACT: Background Since 2000, systemic thrombolysis has been the only approved curative and causal treatment for acute ischemic stroke. In 2009, the guidelines of the German Society for Neurology were updated and the therapeutic window for performing thrombolysis was extended. The implementation of new therapies is influenced by many factors. We analyzed the factors at the organizational level that influence the implementation of thrombolysis in stroke patients.Methods The data published by the majority of German hospitals in their structured quality reports was assessed. We calculated a regression model in order to measure the influence of hospital/department-level characteristics (e.g., teaching status, ownership, location, and number of hospital beds) on the implementation of thrombolysis in 2006 (this is the earliest point in time that can be analyzed on this data basis). In order to measure the effect of the guideline update in 2009 on the thrombolysis rate (TR) change between 2008 and 2010, we performed a Wilcoxon signed-rank test and utilized a regression model.ResultsIn 2006, 61.5% of a total of 286 neurology departments performed systemic thrombolysis to treat ischemic strokes. The influencing factors for the use of systemic thrombolysis in 2006 were the existence of a stroke unit (+) and a hospital size of between 500 and 1,000 beds (¿). A significant increase of the mean departmental TR (thrombolysis rate) from 6.7% to 9.2% between 2008 and 2010 was observed after the guideline update in 2009. For the departments performing thrombolysis in 2008 and 2010, our analysis could not show any additional influencing factors on a structural level that would explain the TR rise during the period 2008¿2010.Conclusions Because ischemic stroke patients benefit from systemic thrombolysis, it is necessary to examine possible barriers at the organizational level that hinder the implementation. Our data shows that, organizational factors have an influence on the implementation of thrombolysis. However, the recent guideline update resulted in a TR rise that occurred at all hospitals, regardless of the measured structural conditions, as our analysis could not identify any structural factors that might have influenced the TR after the guideline update.
    Implementation Science 01/2015; 10(1):10.
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    ABSTRACT: Background Improving the quality of care at hospitals is a key next step in rebuilding Liberia¿s health system. In order to improve the efficiency, effectiveness, and quality of care at the secondary hospital level, the country is developing a system to upgrade health worker skills and competencies, and shifting towards improved provider accountability for results, including a Graduate Medical Residency Program (GMRP) provider accountability for improvements in quality through performance-based financing (PBF) at the hospital level.Methods/designThis document outlines the protocol for the impact evaluation of the hospital improvement program. The evaluation will provide an estimate of the impact of the project and investigate the mechanism for success in a way that can provide general lessons about the quality of health care in low-income countries. The evaluation aims 1) to provide the best possible estimate of program impact and 2) to quantitatively describe the changes that took place within facilities as a result of the program. In particular, the impact evaluation focuses on the changes in human resources within the hospitals. As such, we use a three-period intensive evaluation of treated and matched comparison hospitals to see how services change in treated hospitals as well as a continuous data collection effort to track the activities of individual health workers within treated hospitals.DiscussionWe are particularly interested in understanding how facilities met quality targets. Did they bring in new health workers with higher qualifications? Did they improve the knowledge or competence of their existing staff? Did they improve the availability of medicines and equipment so that the capacities of existing health workers were improved? Did they address the motivation of health workers so that individuals with the same competence and capacity were able to provide higher quality? And, if they did improve quality, did patients notice?
    Implementation Science 01/2015; 10(1):9.
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    ABSTRACT: Background Evidence suggests that rehabilitation interventions can improve function and quality of life in survivors of head and neck cancer (HNC), but there is a lack of coordinated, integrated services, and those offered are inconsistent. To address these gaps, we will develop and conduct preliminary evaluation of a rehabilitation consult, built on the theoretical foundations of goal setting and self-management, and composed of a brief functional evaluation, a resource compendium, and collaborative goal-setting and action planning processes.Methods/designThe development of the rehabilitation consult will be guided by intervention mapping, which consists of six steps: 1. Needs assessment; 2. Definition of program objectives; 3. Selection of theory-based intervention methods; 4. Production and pretesting; 5. Adoption, implementation and sustainability planning; 6. Process and effect evaluation. Within the intervention mapping framework, an iterative process of constructing drafts and mini-evaluations with consumers and experts will be used, modifying the rehabilitation consult intervention until a version suitable for formal evaluation is established. The rehabilitation consult will then be evaluated using a prospective, mixed method, single group design with 30 survivors of head and neck cancer. Outcomes will be assessed pre- and post-intervention and at 6-month follow-up.DiscussionSurvivors of head and neck cancer have among the most complex rehabilitation needs of all cancer patients. The rehabilitation consult is expected to improve knowledge and uptake of rehabilitation resources and strategies in survivors of head and neck cancer and thereby improve long-term function and quality of life. If the rehabilitation consult is effective in cancer patients with such high and diverse needs, this project will produce a toolkit that will be adaptable for other types of cancer in other jurisdictions.
    Implementation Science 01/2015; 10(1):6.
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    ABSTRACT: Background Implementation of clinical practice guidelines into daily care is hampered by a variety of barriers related to professional knowledge and collaboration in teams and organizations. To improve guideline concordance by changing the clinical decision-making behavior of professionals, computerized decision support (CDS) has been shown to be one of the most effective instruments. However, to address barriers at the organizational level, additional interventions are needed. Continuous monitoring and systematic improvement of quality are increasingly used to achieve change at this level in complex health care systems. The study aims to assess the effectiveness of a web-based quality improvement (QI) system with indicator-based performance feedback and educational outreach visits to overcome organizational barriers for guideline concordance in multidisciplinary teams in the field of cardiac rehabilitation (CR).MethodsA multicenter cluster-randomized trial with a balanced incomplete block design will be conducted in 18 Dutch CR clinics using an electronic patient record with CDS at the point of care. The intervention consists of (i) periodic performance feedback on quality indicators for CR and (ii) educational outreach visits to support local multidisciplinary QI teams focussing on systematically improving the care they provide. The intervention is supported by a web-based system which provides an overview of the feedback and facilitates development and monitoring of local QI plans. The primary outcome will be concordance to national CR guidelines with respect to the CR needs assessment and therapy indication procedure. Secondary outcomes are changes in performance of CR clinics as measured by structure, process and outcome indicators, and changes in practice variation on these indicators. We will also conduct a qualitative process evaluation (concept-mapping methodology) to assess experiences from participating CR clinics and to gain insight into factors which influence the implementation of the intervention.DiscussionTo our knowledge, this will be the first study to evaluate the effect of providing performance feedback with a web-based system that incorporates underlying QI concepts. The results may contribute to improving CR in the Netherlands, increasing knowledge on facilitators of guideline implementation in multidisciplinary health care teams and identifying success factors of multifaceted feedback interventions.Trial registration NTR3251.
    Implementation Science 12/2014; 9(1):780.
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    ABSTRACT: Background Through a national policy agreement, over 167 million Euros will be invested in the Swedish National Quality Registries (NQRs) between 2012 and 2016. One of the policy agreement¿s intentions is to increase the use of NQR data for quality improvement (QI). However, the evidence is fragmented as to how the use of medical registries and the like lead to quality improvement, and little is known about non-clinical use. The aim was therefore to investigate the perspectives of Swedish politicians and administrators on quality improvement based on national registry data.Methods Politicians and administrators from four county councils were interviewed. A qualitative content analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed.ResultsThe politicians¿ and administrators¿ perspectives on the use of NQR data for quality improvement were mainly assigned to three of the five CFIR domains. In the domain of intervention characteristics, data reliability and access in reasonable time were not considered entirely satisfactory, making it difficult for the politico-administrative leaderships to initiate, monitor, and support timely QI efforts. Still, politicians and administrators trusted the idea of using the NQRs as a base for quality improvement. In the domain of inner setting, the organizational structures were not sufficiently developed to utilize the advantages of the NQRs, and readiness for implementation appeared to be inadequate for two reasons. Firstly, the resources for data analysis and quality improvement were not considered sufficient at politico-administrative or clinical level. Secondly, deficiencies in leadership engagement at multiple levels were described and there was a lack of consensus on the politicians¿ role and level of involvement. Regarding the domain of outer setting, there was a lack of communication and cooperation between the county councils and the national NQR organizations.Conclusions The Swedish experiences show that a government-supported national system of well-funded, well-managed, and reputable national quality registries needs favorable local politico-administrative conditions to be used for quality improvement; such conditions are not yet in place according to local politicians and administrators.
    Implementation Science 12/2014; 9(1):777.
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    ABSTRACT: Economic evaluations can inform decisions about the efficiency and allocation of resources to implementation strategies¿strategies explicitly designed to inform care providers and patients about the best available research evidence and to enhance its use in their practices. These strategies are increasingly popular in health care, especially in light of growing concerns about quality of care and limits on resources. But such concerns have hardly motivated health authorities and other decision-makers to spend on some form of economic evaluation in their assessments of implementation strategies. This editorial addresses the importance of economic evaluation in the context of implementation science¿particularly, how these analyses can be most efficiently incorporated into decision-making processes about implementation strategies.
    Implementation Science 12/2014; 9(1):168.